Form Dr-1 - Application To Collect And/or Report Tax In Florida (2001) (Page 5 of 5) in pdf

DR-1

SECTION E — GROSS RECEIPTS TAX

R. 08/01

Page 5

40.

Do you sell electrical power or gas? If yes, answer questions a and b below. ....................................................................

Yes

Do you sell:

a. Electrical power? ..................................................................................................................................................................

Yes

b. Natural or manufactured gas? ...............................................................................................................................................

Yes

41.

Do you own or operate a dry-cleaning dry drop-off facility or plant in Florida? ..............................................................

Yes

If yes, enclose the $30 dry-cleaning registration fee.

42.

Do you produce or import perchloroethylene? .....................................................................................................................

Yes

If yes, you must complete an Application for Florida License to Produce or Import Taxable Pollutants (Form DR-166).

SECTION F — DOCUMENTARY STAMP TAX

43.

Do you make sales, finalized by written agreements, that do not require recording by the

Clerk of the Court, but do require documentary stamp tax to be paid? If yes, answer questions 44-46. .......................

Yes

44.

Do you anticipate five or more transactions subject to documentary stamp tax per month? ....................................................

Yes

45.

Do you anticipate your average monthly documentary stamp tax remittance to be less than $80 per month? .........................

Yes

46.

Is this application being completed to register your first location to collect documentary stamp tax? ....................................

Yes

If no, and this application is for additional locations, please list name and address of each additional location.

(Attach additional sheets if needed.)

Location name _________________________________________

Telephone number _____________________________________________

Address ______________________________________________

City/State/ZIP ________________________________________________

SECTION G — COMMUNICATIONS SERVICES TAX

Yes

47.

Do you sell communications services or operate a substitute communications system? If yes, check the items below that apply.

a. Telephone service (local, long distance, or mobile) .............................................................................................................

Yes

b. Paging service .......................................................................................................................................................................

Yes

c. Facsimile (fax) service (not in the course of advertising or professional services) .............................................................

Yes

d. Telex, telegram, or teletype service ......................................................................................................................................

Yes

e. By-pass service .....................................................................................................................................................................

Yes

f. Cable service ........................................................................................................................................................................

Yes

g. Direct-to-home satellite service ............................................................................................................................................

Yes

h. Pay telephone service or prepaid calling arrangements .......................................................................................................

Yes

i. Alternative access vendor service .........................................................................................................................................

Yes

j. Shared tenant utility service .................................................................................................................................................

Yes

k. Other communications services (describe) _________________________________________________________________________________

48.

Have you purchased, installed, rented, or leased a substitute communications system? ...........................................................

Yes

SECTION H — APPLICANT DECLARATION AND SIGNATURE

This application will not be accepted if not signed by the applicant.

Please note that any person (including employees, corporate directors, corporate officers, etc.) who is required to collect, truthfully account for, and

pay any taxes and willfully fails to do so shall be liable for penalties under the provisions of s. 213.29, Florida Statutes (F.S.). All information

provided by the applicant is confidential as provided in s. 213.053, F.S., and is not subject to Florida Public Records Law (s. 119.07, F.S.).

Under penalties of perjury, I declare that I have read the foregoing application and that the facts stated in it are true.

SIGN

HERE ______________________________________________________________

Title __________________________________________

Print name ____________________________________________________________

Date __________________________________________

Amount enclosed: $_____________________ (See table at top of page 1 for fee due with this application.)

NOTE: If the applicant is a sole proprietorship, the proprietor or owner must sign; if a partnership, a partner must sign; if a corporation, an officer of

the corporation authorized to sign on behalf of the corporation must sign; if a limited liability company, an authorized member or manager must sign;

if a trust, a trustee must sign; if applicant is represented by an authorized agent for unemployment tax purposes, the agent may sign (attach executed

power of attorney). THE SIGNATURE OF ANY OTHER PERSON WILL NOT BE ACCEPTED.

USE THIS CHECKLIST TO ENSURE FAST PROCESSING OF YOUR APPLICATION.

✓

Mail to: FLORIDA DEPARTMENT OF REVENUE

Complete application in its entirety.

✓

5050 W TENNESSEE ST

Sign and date the application.

✓

TALLAHASSEE FL 32399-0100

Attach check or money order for appropriate registration fee amount.

You may also mail or deliver to any service center listed on the front page.